bennieyoung
Guru
I am being audited and I used I51.89 as a diagnosis. The auditor wants me to Revise I51.89 to I51.3. She says...The physician documents under findings: "The mass appeared to be subacute thrombotic mass associated with an area in the right atrium that was fibrotic and thickened. It appeared in an area where her dialysis catheter may have been chronically irritating the wall of the atrium. The evidence for this was a thick and fibrotic base to this clot."
I responded... Notes do also say, “right atrial clot”, but then in findings it says, “mass appeared to be subacute thrombotic mass associated with an area in the right atrium that was fibrotic and thickened”. It is definitely still a clot, based on the findings so I think the “appeared to be” part was about the associated with the area in the right atrium? But it says again later, “appears to be a large clot”, but that was on echo. But then during the procedure they call it a “mass” that “appears to be a thrombus”. Note also says it was sent for pathology and the path report doesn’t call it a clot either. So, I went with the I51.89. It is regularly regularly referred to as a mass consistent with a clot or a thrombus. Am I wrong?
PREOPERATIVE DIAGNOSIS: Presumptive endocarditis with a large right atrial clot.
POSTOPERATIVE DIAGNOSIS: Presumptive endocarditis with a large right atrial clot.
PROCEDURE PERFORMED:
1. Resection of right atrial mass.
2. Inspection of tricuspid and aortic valves.
FINDINGS: The pericardial space was free. The aorta was soft. The mass appeared to be subacute thrombotic mass associated with an area in the right atrium that was fibrotic and thickened. It appeared in an area where her dialysis catheter may have been chronically irritating the wall of the atrium. The evidence for this was a thick and fibrotic base to this clot. The tricuspid valve was normal. The mitral valve was normal on transesophageal echo. Examination of the aortic valve reveals a fenestration of the non coronary leaflet. No other abnormalities were identified.
INDICATIONS: The patient is a 78-year-old woman was admitted with signs and symptoms of sepsis. She had a tunneled hemodialysis catheter in the right atrium and echocardiography reveals this is associated with what appears to be a large clot. She had positive blood cultures and there was a question of abnormalities on her tricuspid and aortic valves. She is taken to the operating room now for resection of this mass and valve examination.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in supine position. After the induction of general anesthesia and a single-lumen endotracheal tube intubation, the patient was prepped and draped sterilely. A standard median sternotomy was performed. The patient was fully heparinized. She was cannulated with a Sarns 8.0 soft-flow aortic cannula, as well as 24-French and 28-French SVC and IVC cannulas. Cardiopulmonary bypass was instituted. The cross-clamp was applied and the heart was arrested with 1 L of Del Nido solution. We opened the right atrium to begin with and immedicably identified this mass, which was just medial to the inferior vena cava, and it was a very friable mass. We sent some of this for culture. We also sent for pathology. We scraped this off the atrial wall, which at the base of this complex, what appeared to be thrombus, the atrium was very thickened and fibrotic, appearing as though it may have had chronic irritation. Maybe perhaps from the tip of her dialysis catheter. Once this was completely debrided, the right atrium was then closed. The aorta was opened. The aortic valve was inspected and it was found to have a small fenestration on the edge of the non coronary leaflet. The aorta was then closed and the cross-clamp was removed. The patient was separated from bypass without difficulty. Left, right, and mediastinal chest tubes were placed as well as 2 ventricular pacing wires. Protamine was administered, as well as platelets and FFP. Once hemostasis had been achieved, the heart was then covered with pericardium and fat. The chest was closed #6 stainless steel wire. The subcutaneous tissue and skin were closed with running Vicryl suture.
I responded... Notes do also say, “right atrial clot”, but then in findings it says, “mass appeared to be subacute thrombotic mass associated with an area in the right atrium that was fibrotic and thickened”. It is definitely still a clot, based on the findings so I think the “appeared to be” part was about the associated with the area in the right atrium? But it says again later, “appears to be a large clot”, but that was on echo. But then during the procedure they call it a “mass” that “appears to be a thrombus”. Note also says it was sent for pathology and the path report doesn’t call it a clot either. So, I went with the I51.89. It is regularly regularly referred to as a mass consistent with a clot or a thrombus. Am I wrong?
PREOPERATIVE DIAGNOSIS: Presumptive endocarditis with a large right atrial clot.
POSTOPERATIVE DIAGNOSIS: Presumptive endocarditis with a large right atrial clot.
PROCEDURE PERFORMED:
1. Resection of right atrial mass.
2. Inspection of tricuspid and aortic valves.
FINDINGS: The pericardial space was free. The aorta was soft. The mass appeared to be subacute thrombotic mass associated with an area in the right atrium that was fibrotic and thickened. It appeared in an area where her dialysis catheter may have been chronically irritating the wall of the atrium. The evidence for this was a thick and fibrotic base to this clot. The tricuspid valve was normal. The mitral valve was normal on transesophageal echo. Examination of the aortic valve reveals a fenestration of the non coronary leaflet. No other abnormalities were identified.
INDICATIONS: The patient is a 78-year-old woman was admitted with signs and symptoms of sepsis. She had a tunneled hemodialysis catheter in the right atrium and echocardiography reveals this is associated with what appears to be a large clot. She had positive blood cultures and there was a question of abnormalities on her tricuspid and aortic valves. She is taken to the operating room now for resection of this mass and valve examination.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in supine position. After the induction of general anesthesia and a single-lumen endotracheal tube intubation, the patient was prepped and draped sterilely. A standard median sternotomy was performed. The patient was fully heparinized. She was cannulated with a Sarns 8.0 soft-flow aortic cannula, as well as 24-French and 28-French SVC and IVC cannulas. Cardiopulmonary bypass was instituted. The cross-clamp was applied and the heart was arrested with 1 L of Del Nido solution. We opened the right atrium to begin with and immedicably identified this mass, which was just medial to the inferior vena cava, and it was a very friable mass. We sent some of this for culture. We also sent for pathology. We scraped this off the atrial wall, which at the base of this complex, what appeared to be thrombus, the atrium was very thickened and fibrotic, appearing as though it may have had chronic irritation. Maybe perhaps from the tip of her dialysis catheter. Once this was completely debrided, the right atrium was then closed. The aorta was opened. The aortic valve was inspected and it was found to have a small fenestration on the edge of the non coronary leaflet. The aorta was then closed and the cross-clamp was removed. The patient was separated from bypass without difficulty. Left, right, and mediastinal chest tubes were placed as well as 2 ventricular pacing wires. Protamine was administered, as well as platelets and FFP. Once hemostasis had been achieved, the heart was then covered with pericardium and fat. The chest was closed #6 stainless steel wire. The subcutaneous tissue and skin were closed with running Vicryl suture.